decisionhealth Newsletters, Coder Pink Sheets - 2009 Issue 8 (August)
No credit for reference to prior exams
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Article Overview
This article addresses a common evaluation and management documentation question involving whether clinicians can rely on prior visit documentation to support the exam portion of a current encounter. It explains the broader guidance framework, identifies the limited areas where prior documentation may be referenced, and discusses why the same approach does not apply to current exam elements. The content is aimed at coders, auditors, and providers who work with E/M documentation and compliance.
Why This Topic Matters
Understanding the difference between history elements that may be updated from prior documentation and the need to document current exam findings helps support compliant E/M reporting and accurate medical records.
What You Will Learn
- How the article distinguishes between prior documentation for history elements and current documentation for examination elements.
- What general E/M documentation principles are discussed in relation to coding compliance.
- Why efficient documentation tools are discussed as a workflow consideration.
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Clinical documentation staff
- Practice managers
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